ClearToDrive – D.O.T. Medical Readiness Consultation

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PRE-CONSULTATION QUESTIONNAIRE

Driver Health History

"*" indicates required fields

Name*
Please use the same email used for consultation booking
1. Head/brain injuries or illnesses*
2. Seizures, epilepsy*
3. Eye problems*
4. Ear and/or hearing problems*
5. Heart disease, heart attack, bypass, or other heart problems*
6. Pacemaker, stents, implantable devices, or other heart procedures*
7. High blood pressure*
8. High cholesterol*
9. Chronic cough, shortness of breath, or other breathing problems*
10. Lung disease*
11. Kidney problems, kidney stones, or pain/problems with urination*
12. Stomach, liver, or digestive problems*
13. Diabetes or blood sugar problems*
14. Anxiety, depression, nervousness, or other mental health problems*
15. Fainting or passing out*
17. Unexplained weight loss*
18. Stroke, mini-stroke (TIA), paralysis, or weakness*
19. Missing or limited use of arm, hand, finger, leg, foot, toe*
20. Neck or back problems*
21. Bone, muscle, joint, or nerve problems*
22. Blood clots or bleeding problems*
23. Cancer*
24. Chronic infection or other chronic diseases*
25. Sleep disorders, pauses in breathing while asleep, daytime sleepiness, loud snoring*
26. Have you ever had a sleep test*
27. Have you ever spent a night in the hospital*
28. Have you ever had a broken bone*
29. Have you ever used or do you now use tobacco*
30. Do you currently drink alcohol*
31. Have you used an illegal substance within the past two years*
32. Have you ever failed a drug test or been dependent on an illegal substance*
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